HomeMy WebLinkAboutWell info MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bonng `L�
WELL OR BORING LOCATION � g i f7 1 8 4��� �_
ry WELL AND BORING SEALING RECORD Sealm No.
Coun Name Minnesota Unique No. —
}��{ /� Mmnesota Statutes,Chapter 1031 or W-series No. �
H�niiG �'1 ILeaveblankilnpiknown)
Township Name Townshlp No. Range No. Section No. Fracuon�sm.�Ig.) Date Sealed Date Wetl or Bonng Constn,ctea
Orono 117 23 �8 3�-�403 N�v -�i�i
Numencal Street Adtlress or Fire Number and Gry of Well or Bonng Locatwn �"`a ( /
2392 Bald�� rB�R R� Qr0(�� DepthBeforeSealmg /G—• ft OriglnalDepth �� tl
Slaw exad bcation ot w•ell or boring Sketch map ol well or bonng AO IFER(S) . STATIC WATER LEVEL
in section gnd wrth'X'. � �� location, showing property Single Aqwfer � MulGaquifer
lines,ioads,an wlding�•
N � ��4 WELUBORING Measuretl ❑ Esumated
' �Water Supply Well ❑Monit.Well /
� ` � ❑ Env.Bore Hole ❑Other _ �� R. �elow ❑above land wAace
W -,r- -i-- -�— --;---E ING TY E(S)
r
� CAS P
� � ---__.... ,
� � � �
-,r- -�-- -;-- -�— .� � � � �teel ❑ Plastic ❑Tile �Other
�c mr� �
—�- -�-- -�-- -i— � i_�.__ CASING
� � .�... Diameter Depih � Set m oversize hole9 qrvxialar space irrpa�y gro�
�'�� [\'"` ��/ �
'% ._..+ in.rrom O to� n. ❑ ves No O ves ❑No ❑urruwwn
PROPERTV OWNER'S NAME in.irom to fl. ❑ Yes ❑No ❑Y�s ❑� ❑��"�
Lauri� Q'Keefe
Property ownefs rtwNrg a0tlress if diHerent Ihan wall location address indicaied above. in.hom to R. ❑ �es ❑� ❑Y� ❑� ❑�°��
P��• 17OX 1 1 2 7� SCREEWOPEN NOLE �
5� r aul s t il� 5 5 i 1 i Screen from �� to �� k. Open Hole from b 8.
OBSTRUCTIONS
WELL OWNER'S NAME �RodslDrop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstnictim
�j Q/ �)�y,�i+
WM ownefs meilirq atlOress H Ailferent Man property owner's aAtlress indicated above. Typ9 ot ObsUuctiOns(DesCribe) ,�����1`•- ��/ ` Q" �U�i `/
Obstruclions removed? Yes ❑ No Describe
PUMP �L. f� ('�
1� V�J I t.?�i"
fiEOLO(i1CAL WTERIAL COLOR HApDNESS OF FROM TO Aemoved ❑ Not Present ❑ Other
FORMATION
M rq1 Ivqwn,inOicale esaneted formation bg from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASNC AIO B01iE HOIE:
d r i f t � �� No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing PertoratioNRemoval
in.from to ft. ❑ �a1ed ❑ Henwvad
in.from to It. ❑ PeAoraled ❑ Renaved
Type of pertorator
❑ omer
GROUTING MATERIAL(S)
/
Grouting Material��A�� ���"'f� Q to� R ymds� bps
from to 1L yards b�eps
from to R yaid4 bps
trom to R yaids 6eps
REYARKS,SOUIICE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on praperty? ❑Yes No How n��/?
LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION
This well or boring was sealed in axordence with Minnesota Rules,Chapter 4725. The irormt0a�caMa�rd in�is iaport is
true to the best of my knowledge.
� �?an Stodola t�ell nrilling Co. , Inc. 27I?2
Contrador Business Name f) j Licienss or RsgeBeean Ka
.......-.....�l� *L"i �" �
1 1
fafn�e Signehne�'' Orls
Jira Antonaon
1�^�^� Neme o/Person Seeling Wep or Bonng
LOCAL COPY H V RJ
ME-01r3403 �R